Hemsley, Joanne - non-inquest findings

Contributing factors

• Occlusion of small diagonal branch vessel during percutaneous coronary intervention
• Failure to document procedural complication in medical record
• Absence of clear clinical handover regarding procedural complications
• Failure to order cardiac enzyme testing despite post-procedure chest pain and ECG changes
• Early discharge without appropriate period of monitoring post-complication
• Lack of serial cardiac enzyme monitoring
• Inadequate documentation in operation report
• Absence of documented discussion regarding dissection of stented artery

Coroner's recommendations

1. Coronary Clinical Pathways amended to ensure CK and Troponin testing the morning following the procedure if the patient has prolonged chest pain post-procedure requiring intravenous narcotics
2. Implementation of Chest Pain Management procedure for CCU and Ward 3E to ensure accurate assessment and prompt management of myocardial ischaemia and monitoring
3. Implementation of Coronary Angioplasty – Care of Patient CCU procedure requiring prior to discharge: review by medical officer, 12-lead ECG, CK testing at 06:00 the next morning for patients with prolonged chest pain requiring IV narcotics, with results reviewed by interventional fellow or registrar
4. Implementation of Cardiac Catheter Preparation procedure for standardised care pre and post-operatively
5. Implementation of Nursing Handover procedure promoting interactive and accurate transfer of patient information shift to shift with bedside handover
6. Implementation of Documentation in CCU procedure requiring detailed and accurate documentation of acute cardiac events and routine observations
7. Implementation of Admission of Patient to CCU procedure ensuring effective preparation and assessment
8. Director of Cardiology to speak to all Consultants regarding need for improved handover and documentation of complications with clear treatment plan
9. Implementation of 5pm formal handover meeting for Registrars in the CCU for consistent and thorough medical handover
10. Electronic medical records (iEMR) now manage medical records with automatic transfer of date and time-stamped ECG results
11. Development of new patient brochures with specific information for radial approach coronary procedures